Comparation of non-intralesional or intralesional spondylectomy for chondrosarcoma in mobile spine: a retrospective study of surgery management, complications, and prognosis.

Comparation of non-intralesional or intralesional spondylectomy for chondrosarcoma in mobile spine: a retrospective study of surgery management, complications, and prognosis. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparation of non-intralesional or intralesional spondylectomy for chondrosarcoma in mobile spine: a retrospective study of surgery management, complications, and prognosis. Fangzhi Liu, Ben Wang, Xiaoguang Liu, Fengliang Wu, Hua Zhou, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5317617/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Study Design: Retrospective Cohort Study Objectives: Chondrosarcoma of mobile spine is a rare aggressive malignant tumor and postsurgical local recurrence rates remain high. En bloc resection is currently the preferred treatment. Resection that achieves non-intralesional removal of the tumor may enable more complete removal of tumor tissue but significantly increases the complexity and risk of surgery and results in more postoperative complications. We sought to compare surgical outcomes, complications, and prognoses between patients who underwent en bloc resection with and without intralesional removal of the tumor. Methods: We reviewed 56 patients with spinal chondrosarcoma who underwent en bloc tumor resection and reconstructive surgery at our center between 2000 and 2024 with a minimum postoperative follow-up of 1 year. We collected and analyzed data regarding surgical procedures, complication characteristics, and local tumor control and recurrence. Results: We included 56 patients. Of these, 36 patients underwent the first surgery, and 20 experienced recurrences. All patients underwent en bloc tumor resection; 36 and 20 underwent intralesional and non-intralesional resections, respectively. We recorded 83 complications; the incidence and the number of major complications were significantly higher in the non-intralesional surgery group. Thirty patients experienced tumor recurrence and 26 patients died. Non-intralesional en bloc resection and conventional-type chondrosarcoma were predictive factors for reduced long-term postoperative recurrence and mortality risk. Conclusions: Non-intralesional resection carries higher risks and is associated with a greater number of perioperative complications, but reduces the risk of local tumor recurrence and prolongs recurrence-free survival and overall survival, providing patients with better prognoses. chondrosarcoma mobile spine en-bloc spondylectomy surgical margin complication prognosis Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 INTRODUCTION Chondrosarcoma of the spine is a rare malignant tumor, accounting for approximately 2–12% of all chondrosarcomas [1-3]. Non-surgical treatments, such as chemotherapy and radiotherapy, are ineffective in controlling local tumor growth and invasion. Consequently, en bloc resection is the preferred treatment for spinal chondrosarcoma [3-8]. This surgical approach involves the removal of the affected bone and soft tissue at one time, aiming to minimize local recurrence and distant metastasis. En bloc resection can be categorized into intralesional surgery, which invades the tumor, and non-intralesional surgery, which avoids passing through the tumor and includes marginal and wide-margin resections [9-11]. Retrospective studies of patients with refractory recurrent spinal chondrosarcoma have demonstrated that achieving wide surgical margins significantly improves recurrence-free survival (RFS) and overall survival (OS) [12]. En bloc resection that achieves non-intralesional removal of the tumor enables a more complete removal of tumor tissue, leading to higher OS rates, improved tumor control, and reduced local recurrence rates. However, the anatomical structure of the spine is complex and wider surgical margins are necessary for non-intralesional procedures—that is, a larger scope of resection—while also avoiding damage to critical structures such as the spinal cord and nerves. This significantly increases the complexity and risk of surgery and results in more postoperative complications [13-18]. Regardless of whether a posterior-only approach or a combined approach is employed for en bloc resection, the surgical risks are high, and perioperative management faces significant challenges. Due to the rarity of spinal chondrosarcoma, few studies have been published comparing en bloc resections with different surgical margins for this condition. Our institution, as one of the largest spinal tumor centers in China, has accumulated a substantial number of primary spinal chondrosarcoma cases. Through a retrospective analysis of these cases, we sought to evaluate diagnostic and therapeutic strategies, compare surgical outcomes, complications, and prognoses between patients who underwent en bloc resection with and without intralesional removal of the tumor, and provide additional insights for the diagnosis and treatment of spinal chondrosarcoma. MATERIALS AND METHODS General information This study was approved by the Ethics Committee of our university hospital (IRB00006761-M2023022) and its implementation adhered to the Declaration of Helsinki. The requirement for informed consent was waived because of the retrospective nature of the study. Between January 1, 2000, and May 31, 2024, our spinal surgery team treated a total of 58 patients with spinal chondrosarcoma, as determined by reviewing our center’s spinal tumor case data. Two patients who received early treatment were lost to follow-up due to incomplete electronic records and changes in contact information. Therefore, a total of 56 patients with confirmed diagnoses who underwent en bloc tumor resection and reconstructive surgery in our department were included in this retrospective study. Inclusion criteria were: primary spinal chondrosarcoma confirmed by final histological diagnosis; no distant visceral metastasis as indicated by preoperative imaging or intraoperative findings; and postoperative follow-up of at least 12 months with available imaging data. Exclusion criteria included: postoperative pathological diagnosis results with other tumors instead of chondrosarcoma; patients with metastatic tumors originating outside the spine; and those who underwent surgeries other than en bloc resection. The retrospective evaluation included patients’ electronic medical records, surgical records, anesthesia records, pathology reports, and imaging information. Data collected comprised patients’ age, gender, clinical presentations, neurological function, tumor involvement of vertebral bodies and associated structures, surgical methods, operation time, estimated intraoperative blood loss, postoperative pathology, length of hospital stay, and treatment-related complications. Additionally, the pathological classification of chondrosarcoma in postoperative specimens was documented. Neurological function was assessed using the modified Frankel grading system. Enneking staging was determined based on imaging findings. Imaging and biopsy All patients routinely underwent anteroposterior and lateral spinal radiographs, computed tomography (CT), and magnetic resonance imaging (MRI). Bone scans and positron emission tomography-CT were performed when necessary to exclude systemic metastasis. CT angiography was conducted if tumors were anatomically closely associated with major vascular structures. CT-guided percutaneous tumor biopsy was routinely performed for patients without a definitive preoperative histopathological diagnosis. Treatment protocol In clinical practice, the management of spinal chondrosarcoma begins with assessing the patient’s clinical presentation. Emergency surgical treatment is performed if the patient experiences acute worsening of neurological symptoms—such as pain, sensory and motor disturbances—or even complete loss of neurological function. If the patient’s condition is stable with slowly progressing symptoms, a CT-guided percutaneous biopsy is routinely conducted to confirm the diagnosis and to further determine the treatment and surgical plan. Surgical decisions are made through multidisciplinary team (MDT) collaboration [19], involving spine surgeons, general surgeons, thoracic surgeons, interventional vascular surgeons, anesthesiologists, radiologists, pathologists, and others. En bloc resection is indicated for spinal chondrosarcomas originating from extradural spinal osseous tissue without distant visceral metastasis. All procedures were performed by experienced surgeons. The surgical plan, including the choice of surgical approach, was determined based on tumor location, size, extent of involvement, the patient’s overall health status, and the results of MDT discussions, with reference to the Weinstein-Boriani-Biagini (WBB) staging system [11, 20]. Routine preoperative embolization of the tumor’s feeding arteries was performed before non-intralesional surgeries to reduce surgical difficulty and risk by occluding the tumor’s blood supply and inhibiting its growth [21]. Following resection, spinal reconstruction was typically achieved using 3D-printed artificial vertebral bodies or titanium mesh in combination with titanium plates, pedicle screws, and bone graft fusion with internal fixation. Pathological examination is the gold standard for diagnosing chondrosarcoma. To better analyze this cohort of en bloc resection cases, we defined en bloc resection as the complete removal of the tumor along with a layer of surrounding healthy tissue. Intraoperatively, if there was macroscopic transgression of the tumor, the procedure was classified as intralesional resection; if there was no macroscopic transgression at the surgical margin, it was classified as non-intralesional en bloc resection. All surgical resection specimens underwent pathological examination. Patients who underwent intralesional resection routinely received adjuvant radiotherapy or chemotherapy postoperatively. For those who underwent non-intralesional resection, the surgical margins of the specimens were pathologically assessed for further classification: if positive margins were present, it was classified as a marginal en bloc resection, and adjuvant radiotherapy or chemotherapy was also administered; if all surgical margins were negative, it was considered a wide en bloc resection, and postoperative radiotherapy or chemotherapy was not routinely performed. Perioperative complications were classified according to McDonnell’s criteria as major or minor complications, based on whether they significantly affected patient recovery [22]. Follow-up After discharge, patients were required to undergo imaging examinations at 3, 6, and, 12 months postoperatively, and annually thereafter. CT or MRI scans were performed at each follow-up visit. If patients exhibited symptoms suggestive of local recurrence, immediate CT or MRI examinations were conducted. The minimum follow-up duration was 12 months. Statistical analysis All collected data were analyzed using SPSS Statistics v.27.0 (SPSS Inc., Chicago, IL, USA). The Kolmogorov-Smirnov test was employed to assess the normality of data distributions. Quantitative variables were expressed as means ± standard deviations (SD) for normally distributed data, or as medians with ranges (minimum to maximum) for non-normally distributed data. Differences between groups were evaluated using Student’s t-test for normally distributed data and the Mann-Whitney U-test for non-normally distributed data. Categorical variables are presented as percentages and compared using the chi-squared test or Fisher’s exact test. Survival analyses were conducted using Kaplan-Meier curves and the Cox proportional hazards model. A p-value < 0.05 was considered statistically significant. RESULTS Demographic and clinical characteristics This study included 56 patients, consisting of 28 men and 28 women (Table 1). The mean age at diagnosis was 44.0 years (range 14–71 years). All patients exhibited symptoms of mechanical compression or neurological deficits caused by spinal chondrosarcoma; additionally, 36 patients experienced spinal or limb pain. A total of 24 patients developed spinal cord injury symptoms due to tumor growth, classified according to the Frankel grading system as follows: Grade A (2 patients), Grade B (3 patients), Grade C (6 patients), and Grade D (14 patients). The average duration from symptom onset to surgery was 20.2 months (range 1–120 months). Thirty-six patients had primary tumors, while the remaining 20 patients had recurrences after previous tumor resection. In this study, cases were grouped based on whether the surgical margins transgressed the tumor during surgery. Among the 56 patients, 36 underwent intralesional en bloc resection (Fig. 1-3), while the remaining 20 underwent non-intralesional resection (Fig. 4). The baseline characteristics—including gender, age, length of hospital stay, and whether the tumor was a primary occurrence—were evenly distributed between the two groups, with no statistically significant differences. However, a significant difference was observed in preoperative neurological function between the two groups. Surgical resection method All patients underwent surgical treatment at our center and were confirmed by postoperative pathological diagnosis to have spinal chondrosarcoma. The tumor locations were distributed as follows: 17 cases in the cervical spine, seven in the cervicothoracic spine, 23 in the thoracic spine, one in the thoracolumbar spine, and eight in the lumbar spine. Regarding surgical approaches, two patients underwent anterior-only resection, 27 underwent posterior-only resection, 22 underwent one-stage combined anterior-posterior approach surgery, and five underwent staged combined anterior-posterior approach surgery. The median total operative time was 357.5 minutes (range 107–1,154 minutes), the median intraoperative blood loss was 1,000 mL (range 70–5250 mL), and the median intraoperative blood transfusion volume was 1,100 mL (range 0–6900 mL). In terms of comprehensive postoperative treatments, among patients whose resected margins transgressed the tumor (intralesional resection), 24 received postoperative radiotherapy and nine received postoperative chemotherapy. Among patients whose margins did not transgress the tumor (non-intralesional resection), six received postoperative radiotherapy and one received postoperative chemotherapy. En bloc resection of chondrosarcoma requires a large surgical field and extended operation time, resulting in significant damage to surrounding organs and tissues. Whether the resection transgresses the tumor significantly impacts perioperative management. To elucidate differences between en bloc resections with different surgical margins, we compared tumor characteristics, preoperative preparation, surgical approaches, intraoperative conditions, and postoperative radiotherapy and chemotherapy in patients undergoing intralesional versus non-intralesional surgeries (Table 2). Comparative analysis of the two groups revealed significant differences between intralesional and non-intralesional surgeries in terms of preoperative tumor arterial embolization, total operative time, and postoperative radiotherapy. No statistically significant differences were observed between the groups regarding tumor segment distribution, number of vertebral bodies resected, or surgical approach, indicating a balanced distribution between the groups. Additionally, no significant differences were found in total intraoperative blood loss, total intraoperative blood transfusion volume, or postoperative chemotherapy rate between the two groups. Seven patients (12.5%) experienced dural tears during surgery, resulting in cerebrospinal fluid (CSF) leakage. Larger tears were repaired intraoperatively, and all healed after conservative postoperative treatment. In cases of large chondrosarcomas, especially those involving the thoracic spine, adhesion of the tumor mass to the parietal pleura or penetration of the visceral pleura led to tears or damage to the parietal or full-thickness pleura in 11 patients (19.6%) during surgery. Among these, one patient had lung tissue damage. All injuries were promptly repaired by the surgeon or thoracic surgery team. Perioperative complications During the study period, a total of 83 perioperative complications were recorded among 56 patients with spinal chondrosarcoma (Table 3), averaging 1.48 complications per patient. Forty-two patients (75.0%) experienced at least one perioperative complication. Specifically, 17 patients (30.4%) had one complication, 16 patients (28.6%) had two complications, and nine patients (16.1%) had three or more complications. These complications included 57 major and 26 minor events. Thirty-four patients (60.7%) had major complications, and no perioperative deaths were reported. Intraoperative vascular injuries occurred in 16 cases (28.6%), involving the vertebral artery, epidural venous plexus, bone tissue, and intraspinal venous plexus. All cases received immediate vascular suturing. In these patients, the median operative time for non-intralesional surgery was 463 minutes, significantly longer than the 308 minutes for intralesional surgery (p = 0.007). Although no significant difference was observed in intraoperative bleeding and blood loss between the two surgical methods, hemostasis and vascular repair still required substantial time. Dural tears with CSF leakage occurred in seven cases (12.5%), and pleural injuries occurred in 11 cases (19.6%). The incidence of pleural injury was significantly higher in non-intralesional resection than in intralesional resection (p = 0.031). All dural and pleural injuries were immediately repaired during surgery. Regarding early postoperative complications, neurological function deterioration occurred in 12 patients (18.7%). Postoperative manifestations included paralysis, unexpected decreases in limb muscle strength or hypoesthesia, and band-like sensations. The most severe cases exhibited muscle strength of grade 0–1 in both lower limbs, which had not fully recovered by discharge. In two cases, planned intraoperative ligation of lumbar nerves led to decreased muscle strength in the lower limbs. In one case, stimulation of the recurrent laryngeal nerve during surgery resulted in postoperative hoarseness. Fourteen patients (25.0%) developed pleural effusion, requiring thoracentesis, closed thoracic drainage, or long-term thoracic drainage (> 7 days). All patients showed improvement after puncture or drainage. Postoperative pneumonia occurred in four cases (7.1%), which resolved after anti-infection treatment and oxygen therapy. Five patients (8.9%) experienced postoperative anemia and received blood transfusion therapy. Four patients (7.1%) required debridement due to poor wound healing. Among them, one patient had a recurrent cervical chondrosarcoma after surgery at another hospital and underwent intralesional resection at our hospital in 2000. Postoperative wound healing was poor, and the patient still requires intermittent wound dressing changes during follow-up. In one case, intraoperative pleural damage was initially treated conservatively; after tumor resection, plastic surgeons repaired a large muscle defect. On the first postoperative day, wound dehiscence occurred and was managed by the plastic surgery team with debridement and suturing. Two patients (3.6%) developed deep vein thrombosis of the lower limbs, which improved after anticoagulant therapy without other complications such as embolism. Postoperative imaging revealed that in one patient (1.8%), X-ray and CT scans showed slight rightward deviation of the 3D-printed artificial vertebral body, necessitating surgical adjustment. On the eighth postoperative day, the patient underwent wound exploration via a posterior lumbar approach, nerve root exploration, and adjustment of the artificial vertebral body. Postoperative internal fixation was satisfactory. Additionally, two patients (3.6%) developed postoperative chylothorax, and symptoms gradually disappeared after thoracic drainage, dietary control, and parenteral nutritional support. We compared the perioperative complications between intralesional and non-intralesional en bloc tumor resection surgeries (Tables 4–5). In the intralesional surgery group, 25 patients experienced a total of 42 complications, while in the non-intralesional surgery group, 17 patients experienced a total of 41 complications. Statistical analysis revealed that the incidence of major complications was significantly higher in the non-intralesional surgery group compared to the intralesional surgery group (p = 0.028), indicating a statistically significant difference. Although no significant difference was found in the overall complication rate, the number of complications in the non-intralesional surgery group was significantly higher than that in the intralesional surgery group (p = 0.011). These findings suggest that non-intralesional en bloc resection of spinal chondrosarcoma, which requires complete and thorough removal of the tumor and surrounding tissues, entails higher surgical difficulty and is associated with more numerous, complex, and severe perioperative complications. Follow-up and late complications Among the 56 patients, 7 died of tumor recurrence within 1 year postoperatively. The remaining patients were followed for at least 1 year, with an average follow-up duration of 48.1 months. One patient experienced internal fixation failure 38 months after surgery due to fracture of the titanium alloy fixation rod, necessitating revision surgery. This patient was followed-up for a total of 132 months after the first surgery, with no local tumor recurrence. Local tumor control An analysis was conducted on the 56 patients with available follow-up data. Of these, 30 patients experienced tumor recurrence, yielding a recurrence rate of 53.6% (30/56). The mean time to recurrence was 24.8 months (SD = 29.6), and the median time to recurrence was 13.0 months (IQR = 29.0 months). Among the 36 patients who underwent intralesional resection, 25 experienced recurrence, and 24 of these had died by the time of follow-up. In contrast, among the 20 patients who underwent non-intralesional resection, 4 experienced recurrence, and 2 of these had died by the time of follow-up. Comparing postoperative local recurrence rates and mortality rates between the intralesional and non-intralesional en bloc resection groups, the non-intralesional group exhibited a significantly lower postoperative local recurrence rate (20.0% vs. 69.4%) and a markedly lower mortality rate at the final postoperative follow-up (15.0% vs. 52.8%). The RFS was further extended in the non-intralesional group, with a median RFS of 27 months and a median OS of 33.5 months. In comparison, the intralesional resection group had a median RFS of 18.5 months and a median OS of 41 months. Multivariate Cox proportional hazards regression analysis was performed to assess postoperative recurrence and mortality risks, incorporating variables such as surgical margin status (whether the resection transgressed the tumor), tumor histological type, preoperative arterial embolization, total operative time, total intraoperative blood loss, perioperative complications, spinal segments with tumor involvement, involvement of vertebral bodies and accessory structures, and whether the pedicle was involved. Regarding postoperative recurrence, two factors were associated with an increased risk (p < 0.1): surgical resection margins transgressing the tumor, special histological subtype of the tumor, and involvement of the sacral vertebrae. In terms of postoperative mortality, these factors were also linked to an increased long-term risk of death (p < 0.1): surgical resection margins transgressing the tumor, and special histological subtype of the tumor. Univariate log-rank survival analyses were performed on the above factors, and survival curves were plotted using the Kaplan-Meier method. It was further determined that non-intralesional en bloc resection (p = 0.012) and conventional-type chondrosarcoma (p = 0.022) were predictive factors for reduced long-term postoperative recurrence risk (Fig. 5). Similarly, non-intralesional en bloc resection (p = 0.028) and conventional-type chondrosarcoma (p = 0.027) were also predictive factors for reduced long-term postoperative mortality risk (Fig. 6). DISCUSSION Spinal chondrosarcoma is a malignant tumor originating from cartilaginous matrix, accounting for approximately 20–27% of all malignant bone tumors [9, 10]. The annual incidence of spinal chondrosarcoma is approximately one per million population. Primary spinal chondrosarcoma is relatively rare, representing approximately 2–12% of all chondrosarcomas [1-3], and predominantly occurs in adults aged 40 to 60 years; it is uncommon in children and adolescents. Most spinal chondrosarcomas are not sensitive to radiotherapy and chemotherapy, although some agents (such as bisphosphonates and denosumab) have been used in treatment; therefore, surgical resection remains the preferred treatment option [7, 22-25]. En bloc resection surgery has evolved through different surgical techniques. Both non-intralesional and intralesional en bloc resection can be achieved through the WBB resection and total en bloc spondylectomy. Schwab et al. reported on a team that treated 24 patients with primary spinal chondrosarcoma who underwent surgery [26]. Among these patients, 17 achieved negative surgical margins (wide resection). Of these 17 patients, three (18%) died by the last follow-up. In contrast, among seven patients with positive surgical margins (marginal and intralesional resection), three (43%) died by the last follow-up. In a 2000 study by Boriani and colleagues comparing piecemeal and en bloc resection of spinal chondrosarcoma [8], the authors suggested that en bloc resection can effectively prolong postoperative survival time and reduce the risk of local recurrence. Between 2011 and 2016, Wei Xu et al. described 15 cases of non-intralesional en bloc resection of paraspinal chondrosarcoma [27]. Five cases exhibited local recurrence, with an average postoperative recurrence time of 22 months. Yue Zhang et al. reviewed 49 cases of refractory recurrent spinal chondrosarcoma between 2001 and 2017, comparing prognoses between intralesional and non-intralesional resections [12],showing that patients who underwent non-intralesional surgery had significantly higher RFS and OS compared to those who underwent intralesional surgery. However, in 2018, Nisson et al. conducted a systematic review comparing the recurrence and prognosis of 11 non-intralesional surgery patients and 22 intralesional ones for primary spinal chondrosarcoma [28]. No statistically significant differences were observed in recurrence rates and mortality between the two groups. As a result, the relationship among resection methods, treatment efficacy, postoperative outcomes, and complications has not been clearly established through large-scale studies: whether achieving a non-intralesional margin should be the goal remains inconclusive. Perioperative complications In our study, 75% of patients experienced perioperative complications, which is comparable to results reported in previous research, with Demura et al. [15] and Bandiera et al. [18] reporting postoperative complication rates of 67% and 50%, respectively. Regarding the incidence and number of major perioperative complications, the intralesional resection group had significantly lower rates than the non-intralesional resection cohort, indicating that the surgical safety of intralesional resection is relatively higher than that of non-intralesional resection. Major vascular injury is the most common intraoperative complication in en bloc resection of spinal chondrosarcoma, involving the vertebral artery, azygos vein, and paravertebral venous plexus. However, the incidence of such injuries after intralesional and non-intralesional resections (25% and 35%, respectively) showed no significant difference. We believe the main reasons are as follows: First, due to the rich distribution of venous plexuses anterior to the vertebral body, the extensive resection scope during en bloc tumor removal and the difficulty of separating anterior vertebral tissues via the posterior approach, there is a similar risk of major vascular injury regardless of whether the resection margins transgress the tumor. Second, up to 70% of non-intralesional surgeries involved preoperative embolization of the tumor’s feeding arteries—a proportion significantly higher than that in intralesional surgeries, indirectly reducing the risk of major vascular injury caused by surgical manipulation. All patients achieved adequate hemostasis intraoperatively through vascular repair, packing, or electrocoagulation, and no cases of postoperative bleeding occurred. Postoperatively, 12 patients (21.4%) experienced neurological function deterioration, including 6 patients in the intralesional group and 6 in the non-intralesional group. Six patients had unilateral or bilateral nerve roots of the corresponding segments severed and ligated during surgery, causing decreased muscle strength or paralysis of the lower limbs. Tumors resected via both intralesional and non-intralesional surgeries may involve nerve roots; therefore, the incidence of postoperative neurological dysfunction was similar between the two groups, with relatively favorable prognoses. In three patients, postoperative neurological function did not improve, and they remained paraplegic after rehabilitation training, possibly due to delayed spinal cord ischemia. In other cases, muscle strength and sensory function improved or returned to normal at discharge. Pleural effusion is a common postoperative complication, especially after surgery for thoracic spinal chondrosarcoma. In our study, the incidence of pleural effusion was 16.7% in the intralesional group and 40.0% in the non-intralesional group. Indeed, pleural injuries were significantly more frequent in the non-intralesional group (p = 0.031). This higher incidence may be due to more thorough and complete tumor removal, which increases the likelihood of pleural damage during thoracic tumor resection and extended resection margins. The perioperative management of such cases is critical, and closed thoracic drainage is essential. All patients had ceased drainage by the time of discharge, and the effusion gradually resolved. CSF leakage is more common in surgeries for intradural tumors or during revision surgeries for tumor recurrence. The risk of dural tearing is unavoidable when the tumor adheres to the dura mater, regardless of whether the surgery is intralesional or not. In this study, intraoperative dural tears with postoperative CSF leakage occurred in four cases (11.1%) in the intralesional group and three cases (15.0%) in the non-intralesional group. All cases were successfully repaired and healed after conservative treatments such as bed rest and fluid replacement. In summary, compared with intralesional surgery, non-intralesional resection surgery for spinal chondrosarcoma was associated with a higher number of major complications. This suggests that non-intralesional surgery, while achieving a wider resection margin, may cause more trauma to surrounding organs and tissues, leading to an increase in the total number of perioperative complications. Local control Previous studies have fully confirmed that en bloc resection can significantly reduce local recurrence of spinal chondrosarcoma. Fisher et al. [29] analyzing a cohort of 111 spinal chondrosarcoma cases from 1987 to 2011, concluded that Enneking appropriate surgery is associated with a reduced risk of local recurrence but not with OS. In 2023, Abunimer et al. [30] based on a cohort of 72 patients, indicated that total en bloc resection of spinal chondrosarcoma is associated with local recurrence-free outcomes and improved OS. Xing-hai Yang et al. [31] further refined these conclusions, revealing the positive impact of en bloc resection on the prognosis of cervical and cervicothoracic chondrosarcoma. Huabin Yin et al. [32] conducted a retrospective study of 98 cases of spinal chondrosarcoma, emphasizing that total spondylectomy significantly reduces the risk of recurrence and distant metastasis while improving OS. Our study results indicated that non-intralesional en bloc resection of spinal chondrosarcoma can reduce local tumor recurrence, improve survival rates, and extend RFS periods for patients. Although the non-intralesional surgical approach carries higher risks and more complications, choosing a more thorough resection without transgressing the tumor is necessary and valuable for achieving better therapeutic effects and prognosis. On the other hand, since non-intralesional en bloc resection has been applied in recent years with new surgical techniques, the number of cases is smaller, and the follow-up period is obviously shorter compared to intralesional surgery. The currently reported median survival time is also shorter, which may not fully reflect the survival situation after non-intralesional en bloc resection. However, from short-term analyses, it can still be concluded that en bloc resection with tumor-free margins can reduce mortality caused by tumor recurrence and extend the OS of patients with spinal chondrosarcoma. LIMITATIONS This study was a single-center, retrospective analysis and had certain limitations. First, spinal chondrosarcoma is relatively rare, making it challenging to obtain a large sample size for the case cohort. Second, the surgical cases included in this study span a period of 24 years. With the accumulation of surgical techniques and experience, and the advancement of materials and medical technology over time, ensuring consistency in treatment is very difficult. Consequently, when comparing cases from different periods, it is also challenging to eliminate the impact of this factor. CONCLUSION To achieve complete resection of spinal chondrosarcoma and reduce local recurrence, en bloc tumor resection is the preferred treatment. Regarding resection margins, although non-intralesional resection is more difficult and carries higher risks, and is associated with a greater number of perioperative complications, it can reduce the risk of local tumor recurrence, prolong RFS and OS, and provide patients with better prognoses. Therefore, when the condition and general health of patients with spinal chondrosarcoma permit, we recommend non-intralesional en bloc tumor resection surgery. Abbreviations SD standard deviation IQR InterQuartile Range. Declarations Funding Disclosure The authors have no funding resources to declare. Competing interests The authors declare no competing interests. Conflict of Interest The authors declare no potential conflicts of interest. Ethics Statement The study protocol was approved by the institutional research ethics committee ((IRB00006761-M2023022), according to the principles of the Declaration of Helsinki. The institutional review board granted a waiver of informed consent because of the retrospective nature of the study. References Zhang Y, He S, Bi Y, Xu Y, Miao W, Wei H (2021) Refractory recurrent spinal chondrosarcoma: What is the role of salvage surgery? 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J Bone Joint Surg Am Jun 78(6):839–847. 10.2106/00004623-199606000-00006 Stener B (1971) Total spondylectomy in chondrosarcoma arising from the seventh thoracic vertebra. J Bone Joint Surg Br May 53(2):288–295 Domenicucci M, Nigro L, Delfini R (2018) Total en-bloc spondylectomy through a posterior approach: technique and surgical outcome in thoracic metastases. Acta Neurochir (Wien) Jul 160(7):1373–1376. 10.1007/s00701-018-3572-2 Duan PG, Li RY, Jiang YQ et al (2015) Recurrent adamantinoma in the thoracolumbar spine successfully treated by three-level total en bloc spondylectomy by a single posterior approach. Eur Spine J May 24(Suppl 4):S514–S521. 10.1007/s00586-014-3625-z Song RX, Zhang YG, Zhang XS, Zheng GQ, Wang Y (2012) [One-stage total en bloc spondylectomy and reconstruction via a single posterior approach for thoracic vertebral symptomatic hemangioma associated with spinal cord dysfunction]. Zhonghua Wai Ke Za Zhi Apr 50(4):342–345 Xu W, Ye C, Zhang D et al (2022) One-stage En bloc resection of thoracic spinal chondrosarcoma with huge paravertebral mass through the single posterior approach by dissociate longissimus thoracis. Front Surg 9:844611. 10.3389/fsurg.2022.844611 Huang L, Chen K, Ye JC et al (2013) Modified total en bloc spondylectomy for thoracolumbar spinal tumors via a single posterior approach. Eur Spine J Mar 22(3):556–564. 10.1007/s00586-012-2460-3 Yang H, Hou K, Lu N, Xiao S, Wang Y (2016) En bloc spondylectomy combined with chest wall excision for spinal tumor via a modified posterior approach: a retrospective study on 21 patients. Clin Neurol Neurosurg Jan 140:91–96. 10.1016/j.clineuro.2015.11.018 Zaidi HA, Awad AW, Dickman CA (2017) Complete Spondylectomy Using Orthogonal Spinal Fixation and Combined Anterior and Posterior Approaches for Thoracolumbar Spinal Reconstruction: Technical Nuances and Clinical Results. Clin Spine Surg May 30(4):E466–e474. 10.1097/bsd.0000000000000292 Onoki T, Kanno H, Aizawa T, Hashimoto K, Itoi E, Ozawa H (2018) Recurrent primary osseous hemangiopericytoma in the thoracic spine: a case report and literature review. Eur Spine J Jul 27(Suppl 3):386–392. 10.1007/s00586-017-5322-1 Ahmadi SA, Frank S, Hänggi D, Eicker SO (2012) Primary spinal marginal zone lymphoma: case report and review of the literature. Neurosurg Aug 71(2):E495–508 discussion E508. 10.1227/NEU.0b013e31824e50fb Halevi PD, Ramirez-de-Noriega F, Fellig Y, Gomori JM, Cohen JE, Itshayek E (2015) Primary pleomorphic liposarcoma of the thoracic epidural space: case report. Spine J Dec 1(12):e71–e75. 10.1016/j.spinee.2015.08.059 Liu C, Qiu Y, Li T, Wang F (2023) Primary osteosarcoma of the thoracic vertebrae: A case report and literature review. Asian J Surg Jun 46(6):2337–2339. 10.1016/j.asjsur.2022.11.140 Huang X, Pan X, Huang H, Zhan R (2013) Multiple spinal cord melanoma: case report with emphasis on the difficult preoperative diagnosis. Turk Neurosurg 23(4):534–538. 10.5137/1019-5149.Jtn.5351-11.1 Wang YB, Wang WJ, Zhao HT, Li W, Peng T, Zhang XF (2016) Multiple melanocytoma of the thoracic spine: a case report and literature review. Spine J Jan 1 16(1):e59–63. 10.1016/j.spinee.2015.09.036 Ali Y, Rahme R, Moussa R, Abadjian G, Menassa-Moussa L, Samaha E (2009) Multifocal meningeal melanocytoma: a new pathological entity or the result of leptomeningeal seeding? J Neurosurg Sep 111(3):488–491. 10.3171/2009.3.Jns081096 Haque MU, Wilson AN, Blecher HD, Reich SM (2013) Lumbar hemangioma masking a plasma cell tumor–case report and review of the literature. Spine J Aug 13(8):e11–e15. 10.1016/j.spinee.2013.01.050 Uehara M, Takahashi J, Hirabayashi H et al (2013) Hodgkin's disease of the thoracic vertebrae. Spine J Aug 13(8):e59–63. 10.1016/j.spinee.2013.03.026 Kumar R, Vaid VK, Kumar V, Kalra SK (2007) Hemangiopericytoma of thoracic spine: a rare bony tumor. Childs Nerv Syst Oct 23(10):1215–1219. 10.1007/s00381-007-0372-z Yang W, Jiang L, Liu X et al (2018) Surgical complications of extraspinal tumors in the cervical spine: a report of 110 cases and literature review. Eur Spine J Apr 27(4):882–890. 10.1007/s00586-017-5259-4 Tables Tables 1 to 5 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.docx Table2.docx Table3.docx Table4.docx Table5.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5317617","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":370840896,"identity":"2622c6f1-7d02-4220-ad59-5f649a927402","order_by":0,"name":"Fangzhi Liu","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Fangzhi","middleName":"","lastName":"Liu","suffix":""},{"id":370840897,"identity":"2cf5881b-6e42-4c3e-a565-a99f213e4ce9","order_by":1,"name":"Ben Wang","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ben","middleName":"","lastName":"Wang","suffix":""},{"id":370840898,"identity":"5ef62ab9-f0f4-4ed1-a7f6-c1987dd8dae1","order_by":2,"name":"Xiaoguang Liu","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiaoguang","middleName":"","lastName":"Liu","suffix":""},{"id":370840899,"identity":"20302ce4-d745-4f0f-a6a9-ab7ef84afb0e","order_by":3,"name":"Fengliang Wu","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Fengliang","middleName":"","lastName":"Wu","suffix":""},{"id":370840900,"identity":"96bd8abc-c286-47a7-a078-cb13ca269c5a","order_by":4,"name":"Hua Zhou","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hua","middleName":"","lastName":"Zhou","suffix":""},{"id":370840901,"identity":"82265754-813d-41f1-8ffd-a5df67323f4e","order_by":5,"name":"Lei Dang","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lei","middleName":"","lastName":"Dang","suffix":""},{"id":370840902,"identity":"51472297-d13e-4b60-876e-4b7a9a7910d8","order_by":6,"name":"Yan Li","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Li","suffix":""},{"id":370840903,"identity":"15eea91b-a7bb-4913-8f1e-997cdc661353","order_by":7,"name":"Yanchao Tang","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yanchao","middleName":"","lastName":"Tang","suffix":""},{"id":370840904,"identity":"327855fb-acd5-457f-aa6e-28d3c96c01c2","order_by":8,"name":"Xiao Liu","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiao","middleName":"","lastName":"Liu","suffix":""},{"id":370840905,"identity":"15397599-8985-421c-9d9a-8374d7d739c9","order_by":9,"name":"Panpan Hu","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Panpan","middleName":"","lastName":"Hu","suffix":""},{"id":370840906,"identity":"ada94795-40de-4758-87c6-fe23395c1da2","order_by":10,"name":"Zihe Li","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zihe","middleName":"","lastName":"Li","suffix":""},{"id":370840907,"identity":"90ff9018-e0c2-4c7b-b86a-332a8278a0a2","order_by":11,"name":"Feng Wei","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYFACxoYPQFLOgOEAiMdMlJbGGUDSmBQtDIwgLYkbIBwitBgcb25s+LijNn074+k0CYYK68QG9rMH8Gs5c7CxceaZ47k7G85uk2A4k57YwJOXgFeL2Y3E9se8bcdyNxwAamFsO5zYIMFjgF/L/YeNzX/bjqUbgLX8I0bLDcbGZsa2mgSIlgYitNifSWxs7G07YAj0y2aLhGPpxm08Ofi1SLYff9jws61O3lzi7MYbH2qsZfvZz+DXAgWHGRgkDjAwJACZbMSoB4I6Bgb+BiLVjoJRMApGwYgDAMJsUcgObYRyAAAAAElFTkSuQmCC","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":true,"prefix":"","firstName":"Feng","middleName":"","lastName":"Wei","suffix":""},{"id":370840908,"identity":"bfb0d433-d733-486f-8d5e-f7a19162c9ee","order_by":12,"name":"Zhongjun Liu","email":"","orcid":"","institution":"Peking University Third Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhongjun","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2024-10-23 09:23:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5317617/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5317617/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":69420615,"identity":"c88befdc-ee59-4e7f-a4ed-f6f44ace0f36","added_by":"auto","created_at":"2024-11-20 07:43:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":6956671,"visible":true,"origin":"","legend":"\u003cp\u003eThis case involves a 40-year-old female patient with a T9 chondrosarcoma, classified under the WBB staging system as T9 3-10 A-D. In July 2017, the patient underwent a “posterior approach thoracic tumor resection, decompression, bone grafting, and internal fixation surgery” at a local hospital. Postoperative pathology indicated a “mucinous chondrosarcoma.” After receiving postoperative radiotherapy and chemotherapy, the patient was discharged. Two months later, due to residual tumor, the patient was transferred to our hospital seeking further treatment. Upon admission, embolization of the bilateral segmental arteries of T8, T9, and T10 was performed, followed by a staged lateral-posterior approach surgery. The postoperative pathology revealed a high to moderately differentiated chondrosarcoma, and no tumor cells were found in the scar tissue on the surface of the dura mater, achieving an en bloc resection of the tumor without traversing it. The patient received adjuvant radiotherapy postoperatively and, during a two-year follow-up, no local recurrence was observed.\u003c/p\u003e\n\u003cp\u003eA and B: Preoperative MRI and CT images indicated that the tumor involved the T9-10 intervertebral foramina and the medial side of the T10 pedicles. C: In the first stage, a lateral approach was used, preserving the pleura on the tumor surface as a safety margin. D: In the second stage, a posterior approach was used. During surgery, several tears in the dura mater occurred due to scar tissue, all of which were repaired. E: Postoperative specimen. F: Postoperative specimen X-ray images. G: The postoperative specimen CT scans, including coronal vertebral sections, coronal spinal canal sections, and sagittal intervertebral foramen sections, revealed tumor involvement of the T9-10 intervertebral foramina. H: The postoperative specimen CT showed a complete resection while preserving the left attachments. I: Postoperative X-ray and CT images indicate complete tumor resection and satisfactory internal fixation.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-5317617/v1/8365a3f3f65ec235ea1fc6ae.png"},{"id":69420613,"identity":"3d5aa3d8-b0f4-4528-86d2-6a3161a27f53","added_by":"auto","created_at":"2024-11-20 07:43:59","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":7631340,"visible":true,"origin":"","legend":"\u003cp\u003eThis case involves a 38-year-old male patient with a L4 chondrosarcoma, classified under the WBB staging system as L4 4-6 A-B. The patient was admitted to the general surgery department with a large retroperitoneal mass due to chronic constipation. Upon admission, examinations revealed that the tumor originated from the L4 vertebral body, and the neurological examination was normal. A CT-guided biopsy resulted in a diagnosis of well-differentiated chondrosarcoma. After embolization of the segmental arteries, a one-stage en bloc resection surgery was performed using a combined anterior midline-posterior midline-lateral approach without traversing the tumor. Postoperative pathology confirmed a well-differentiated chondrosarcoma (Grade I). The patient received adjuvant radiotherapy and chemotherapy after surgery. During a one-year follow-up, bone fusion was satisfactory, and there was no tumor recurrence.\u003c/p\u003e\n\u003cp\u003eA and B: Preoperative MRI and CT images indicated that the tumor originated from the L4 vertebral body. C: An anterior midline approach was used to separate and isolate the tumor from the ureters and iliac vessels up to the front of the vertebral body. The L3-4 and L5-S1 intervertebral discs were resected. D: A posterior midline approach was used to resect the L4 and L5 posterior elements, separate the nerve roots, remove the L3-4 and L5-S1 intervertebral discs, perform sagittal osteotomies of L4 and L5, and carry out pedicle screw fixation and fusion. E: A lateral approach was used to separate the lateral aspect of the tumor and remove it en bloc, followed by intervertebral fusion from L3 to S1. F, G and H: Surgical resection specimen. I: The postoperative specimen CT shows significant destruction of the vertebral bone, with punctate, patchy, and arc-shaped calcifications visible internally. The lesion boundaries remain relatively clear. J: Postoperative X-ray and CT images indicate good bone fusion and no tumor recurrence.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-5317617/v1/6db8ae0ac8a3871501fcfe65.png"},{"id":69419091,"identity":"240e3d1c-db77-4f6a-9b21-9d263ab974e4","added_by":"auto","created_at":"2024-11-20 07:35:59","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":4447924,"visible":true,"origin":"","legend":"\u003cp\u003eThis case involves a 29-year-old female patient with a T11-L2 chondrosarcoma, classified under the WBB staging system as L1 3-9 A-D. The patient primarily presented with dull and aching pain in the lower back for seven months. An examination at a local hospital revealed a lumbar vertebral tumor, and the neurological examination was normal. A biopsy via puncture diagnosed mesenchymal chondrosarcoma. After undergoing three courses of chemotherapy with IE, VAC, and IE regimens, the patient underwent staged anterior-posterior combined approach surgery at our hospital. This surgery involved en bloc resection of the entire vertebrae from T11 to L2 along with left nephrectomy, achieving tumor removal without traversing the tumor. Postoperative pathology confirmed mesenchymal chondrosarcoma (Grade II-III). The patient received adjuvant chemotherapy and local radiotherapy after surgery. During a three-year follow-up, no tumor recurrence was observed, and the internal fixation remained stable.\u003c/p\u003e\n\u003cp\u003eA and B: Preoperative MRI and CT images indicated that the tumor did not shrink after chemotherapy, with spinal involvement from T11 to L2. C: CT revealed the formation of a tumor thrombus within the left renal vein. D: 3D tumor model and surgical planning for osteotomy sites at each segment. E: Surgical specimen X-ray images. F: Surgical specimen CT images. G: Postoperative X-ray and CT images indicate complete tumor resection and satisfactory internal fixation.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-5317617/v1/ab35d580e6a868ce8e35025c.png"},{"id":69419098,"identity":"67fafeee-1fa4-4820-8f31-fe7eebc9b43c","added_by":"auto","created_at":"2024-11-20 07:35:59","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":8699596,"visible":true,"origin":"","legend":"\u003cp\u003eThis case involves a 36-year-old male patient with a C5 chondrosarcoma, classified under the WBB staging system as C5 1-12 A-C. The patient primarily presented with neck pain accompanied by pain, numbness, and weakness in the left upper limb for nine months and was diagnosed with chondrosarcoma over five months prior to admission. A puncture biopsy revealed a high-grade sarcoma, with dedifferentiated chondrosarcoma being the most likely diagnosis. After undergoing four courses of neoadjuvant chemotherapy, the patient underwent a staged posterior-anterior combined C5 total en bloc spondylectomy at our hospital, achieving extracapsular en bloc resection of the tumor. Postoperative pathology indicated an undifferentiated pleomorphic sarcoma. After discharge, the patient received local radiotherapy and began chemotherapy one month postoperatively.\u003c/p\u003e\n\u003cp\u003eA and B: Preoperative MRI and CT images indicated that the neck soft tissue mass had slightly decreased in size following chemotherapy compared to prior measurements. C and D: A posterior approach was used to resect the C5 lamina and bilateral facet joints. E: A cervical anterior approach was used to achieve resection of the C5 vertebral body and bilateral facet joints. F: Postoperative MRI images. G: Postoperative X-ray shows good internal fixation. H: Postoperative CT images show en bloc resection of the tumor. I: Four months after follow-up, a repeat cervical spine MRI revealed high T2 signals in the soft tissues near the posterior margins of the C7-T1 facets and spinous processes. Pathological biopsy confirmed local recurrence.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-5317617/v1/e0f58261f963532a9b7eeea1.png"},{"id":69419093,"identity":"080737bd-46f9-4128-b5ad-ba128dc82183","added_by":"auto","created_at":"2024-11-20 07:35:59","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":232930,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier curves for postoperative recurrence. (a)Surgical method：intraleisional group and non-intraleisional group.(b)Pathological grading: conventional type and special type.\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-5317617/v1/33a189662199d39e63bf4a15.png"},{"id":69419097,"identity":"10604ed9-3cea-4309-91a9-37d5b24630bd","added_by":"auto","created_at":"2024-11-20 07:35:59","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":224106,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier curves for postoperative death. (a)Surgical method：intraleisional group and non-intraleisional group.(b)Pathological grading: conventional type and special type.\u003c/p\u003e","description":"","filename":"Figure6.png","url":"https://assets-eu.researchsquare.com/files/rs-5317617/v1/b541476a8b96e0b0870f4d54.png"},{"id":71661231,"identity":"68eb988d-c931-4477-89ea-bf79675cc45a","added_by":"auto","created_at":"2024-12-17 13:41:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":26642541,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5317617/v1/2abacdbb-7fe6-421f-a11d-1a2a66447e92.pdf"},{"id":69419089,"identity":"2ce8acc0-05b3-48da-b676-d841757f57ef","added_by":"auto","created_at":"2024-11-20 07:35:59","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":14960,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-5317617/v1/5e61160d79cf889681914678.docx"},{"id":69421243,"identity":"c775f6a0-bb35-45f3-a6f2-fcaa64a38f72","added_by":"auto","created_at":"2024-11-20 07:51:59","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16013,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-5317617/v1/7f2ae4bf367120cf60ec2d28.docx"},{"id":69421244,"identity":"20f203a4-7699-4b2b-bc56-65b089f9066b","added_by":"auto","created_at":"2024-11-20 07:51:59","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":15493,"visible":true,"origin":"","legend":"","description":"","filename":"Table3.docx","url":"https://assets-eu.researchsquare.com/files/rs-5317617/v1/0d844ea7f12a6b043c455b46.docx"},{"id":69419100,"identity":"9201c41b-cce0-4051-9460-750fe7c2a020","added_by":"auto","created_at":"2024-11-20 07:35:59","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":13662,"visible":true,"origin":"","legend":"","description":"","filename":"Table4.docx","url":"https://assets-eu.researchsquare.com/files/rs-5317617/v1/5a505e23cef01afff1fbb510.docx"},{"id":69419096,"identity":"9b62f8d6-fb75-4c08-a2ab-b36c3d56bc82","added_by":"auto","created_at":"2024-11-20 07:35:59","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":13635,"visible":true,"origin":"","legend":"","description":"","filename":"Table5.docx","url":"https://assets-eu.researchsquare.com/files/rs-5317617/v1/949505d453e3b683048148d8.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparation of non-intralesional or intralesional spondylectomy for chondrosarcoma in mobile spine: a retrospective study of surgery management, complications, and prognosis.","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eChondrosarcoma of the spine is a rare malignant tumor, accounting for approximately 2\u0026ndash;12% of all chondrosarcomas [1-3]. Non-surgical treatments, such as chemotherapy and radiotherapy, are ineffective in controlling local tumor growth and invasion. Consequently, en bloc resection is the preferred treatment for spinal chondrosarcoma [3-8]. This surgical approach involves the removal of the affected bone and soft tissue at one time, aiming to minimize local recurrence and distant metastasis. En bloc resection can be categorized into intralesional surgery, which invades the tumor, and non-intralesional surgery, which avoids passing through the tumor and includes marginal and wide-margin resections [9-11]. Retrospective studies of patients with refractory recurrent spinal chondrosarcoma have demonstrated that achieving wide surgical margins significantly improves recurrence-free survival (RFS) and overall survival (OS) [12].\u003c/p\u003e\n\u003cp\u003eEn bloc resection that achieves non-intralesional removal of the tumor enables a more complete removal of tumor tissue, leading to higher OS rates, improved tumor control, and reduced local recurrence rates. However, the anatomical structure of the spine is complex and wider surgical margins are necessary for non-intralesional procedures\u0026mdash;that is, a larger scope of resection\u0026mdash;while also avoiding damage to critical structures such as the spinal cord and nerves. This significantly increases the complexity and risk of surgery and results in more postoperative complications [13-18]. Regardless of whether a posterior-only approach or a combined approach is employed for en bloc resection, the surgical risks are high, and perioperative management faces significant challenges.\u003c/p\u003e\n\u003cp\u003eDue to the rarity of spinal chondrosarcoma, few studies have been published comparing en bloc resections with different surgical margins for this condition. Our institution, as one of the largest spinal tumor centers in China, has accumulated a substantial number of primary spinal chondrosarcoma cases. Through a retrospective analysis of these cases, we sought to evaluate diagnostic and therapeutic strategies, compare surgical outcomes, complications, and prognoses between patients who underwent en bloc resection with and without intralesional removal of the tumor, and provide additional insights for the diagnosis and treatment of spinal chondrosarcoma.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e\u003cstrong\u003eGeneral information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of our university hospital (IRB00006761-M2023022) and its implementation adhered to the Declaration of Helsinki. The requirement for informed consent was waived because of the retrospective nature of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBetween January 1, 2000, and May 31, 2024, our spinal surgery team treated a total of 58 patients with spinal chondrosarcoma, as determined by reviewing our center\u0026rsquo;s spinal tumor case data. Two patients who received early treatment were lost to follow-up due to incomplete electronic records and changes in contact information. Therefore, a total of 56 patients with confirmed diagnoses who underwent en bloc tumor resection and reconstructive surgery in our department were included in this retrospective study. Inclusion criteria were: primary spinal chondrosarcoma confirmed by final histological diagnosis; no distant visceral metastasis as indicated by preoperative imaging or intraoperative findings; and postoperative follow-up of at least 12 months with available imaging data. Exclusion criteria included: postoperative pathological diagnosis results with other tumors instead of chondrosarcoma; patients with metastatic tumors originating outside the spine; and those who underwent surgeries other than en bloc resection.\u003c/p\u003e\n\u003cp\u003eThe retrospective evaluation included patients\u0026rsquo; electronic medical records, surgical records, anesthesia records, pathology reports, and imaging information. Data collected comprised patients\u0026rsquo; age, gender, clinical presentations, neurological function, tumor involvement of vertebral bodies and associated structures, surgical methods, operation time, estimated intraoperative blood loss, postoperative pathology, length of hospital stay, and treatment-related complications. Additionally, the pathological classification of chondrosarcoma in postoperative specimens was documented. Neurological function was assessed using the modified Frankel grading system. Enneking staging was determined based on imaging findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImaging and biopsy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients routinely underwent anteroposterior and lateral spinal radiographs, computed tomography (CT), and magnetic resonance imaging (MRI). Bone scans and positron emission tomography-CT were performed when necessary to exclude systemic metastasis. CT angiography was conducted if tumors were anatomically closely associated with major vascular structures. CT-guided percutaneous tumor biopsy was routinely performed for patients without a definitive preoperative histopathological diagnosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTreatment protocol\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn clinical practice, the management of spinal chondrosarcoma begins with assessing the patient\u0026rsquo;s clinical presentation. Emergency surgical treatment is performed if the patient experiences acute worsening of neurological symptoms\u0026mdash;such as pain, sensory and motor disturbances\u0026mdash;or even complete loss of neurological function. If the patient\u0026rsquo;s condition is stable with slowly progressing symptoms, a CT-guided percutaneous biopsy is routinely conducted to confirm the diagnosis and to further determine the treatment and surgical plan. Surgical decisions are made through multidisciplinary team (MDT) collaboration [19], involving spine surgeons, general surgeons, thoracic surgeons, interventional vascular surgeons, anesthesiologists, radiologists, pathologists, and others.\u003c/p\u003e\n\u003cp\u003eEn bloc resection is indicated for spinal chondrosarcomas originating from extradural spinal osseous tissue without distant visceral metastasis. All procedures were performed by experienced surgeons. The surgical plan, including the choice of surgical approach, was determined based on tumor location, size, extent of involvement, the patient\u0026rsquo;s overall health status, and the results of MDT discussions, with reference to the Weinstein-Boriani-Biagini (WBB) staging system [11, 20]. Routine preoperative embolization of the tumor\u0026rsquo;s feeding arteries was performed before non-intralesional surgeries to reduce surgical difficulty and risk by occluding the tumor\u0026rsquo;s blood supply and inhibiting its growth [21]. Following resection, spinal reconstruction was typically achieved using 3D-printed artificial vertebral bodies or titanium mesh in combination with titanium plates, pedicle screws, and bone graft fusion with internal fixation.\u003c/p\u003e\n\u003cp\u003ePathological examination is the gold standard for diagnosing chondrosarcoma. To better analyze this cohort of en bloc resection cases, we defined en bloc resection as the complete removal of the tumor along with a layer of surrounding healthy tissue. Intraoperatively, if there was macroscopic transgression of the tumor, the procedure was classified as intralesional resection; if there was no macroscopic transgression at the surgical margin, it was classified as non-intralesional en bloc resection.\u003c/p\u003e\n\u003cp\u003eAll surgical resection specimens underwent pathological examination. Patients who underwent intralesional resection routinely received adjuvant radiotherapy or chemotherapy postoperatively. For those who underwent non-intralesional resection, the surgical margins of the specimens were pathologically assessed for further classification: if positive margins were present, it was classified as a marginal en bloc resection, and adjuvant radiotherapy or chemotherapy was also administered; if all surgical margins were negative, it was considered a wide en bloc resection, and postoperative radiotherapy or chemotherapy was not routinely performed.\u003c/p\u003e\n\u003cp\u003ePerioperative complications were classified according to McDonnell\u0026rsquo;s criteria as major or minor complications, based on whether they significantly affected patient recovery [22].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFollow-up\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter discharge, patients were required to undergo imaging examinations at 3, 6, and, 12 months postoperatively, and annually thereafter. CT or MRI scans were performed at each follow-up visit. If patients exhibited symptoms suggestive of local recurrence, immediate CT or MRI examinations were conducted. The minimum follow-up duration was 12 months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll collected data were analyzed using SPSS Statistics v.27.0 (SPSS Inc., Chicago, IL, USA). The Kolmogorov-Smirnov test was employed to assess the normality of data distributions. Quantitative variables were expressed as means \u0026plusmn; standard deviations (SD) for normally distributed data, or as medians with ranges (minimum to maximum) for non-normally distributed data. Differences between groups were evaluated using Student\u0026rsquo;s t-test for normally distributed data and the Mann-Whitney U-test for non-normally distributed data. Categorical variables are presented as percentages and compared using the chi-squared test or Fisher\u0026rsquo;s exact test. Survival analyses were conducted using Kaplan-Meier curves and the Cox proportional hazards model. A p-value \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eDemographic and clinical characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study included 56 patients, consisting of 28 men and 28 women (Table 1). The mean age at diagnosis was 44.0 years (range 14\u0026ndash;71 years). All patients exhibited symptoms of mechanical compression or neurological deficits caused by spinal chondrosarcoma; additionally, 36 patients experienced spinal or limb pain. A total of 24 patients developed spinal cord injury symptoms due to tumor growth, classified according to the Frankel grading system as follows: Grade A (2 patients), Grade B (3 patients), Grade C (6 patients), and Grade D (14 patients). The average duration from symptom onset to surgery was 20.2 months (range 1\u0026ndash;120 months). Thirty-six patients had primary tumors, while the remaining 20 patients had recurrences after previous tumor resection.\u003c/p\u003e\n\u003cp\u003eIn this study, cases were grouped based on whether the surgical margins transgressed the tumor during surgery. Among the 56 patients, 36 underwent intralesional en bloc resection (Fig. 1-3), while the remaining 20 underwent non-intralesional resection (Fig. 4). The baseline characteristics\u0026mdash;including gender, age, length of hospital stay, and whether the tumor was a primary occurrence\u0026mdash;were evenly distributed between the two groups, with no statistically significant differences. However, a significant difference was observed in preoperative neurological function between the two groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical resection method\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients underwent surgical treatment at our center and were confirmed by postoperative pathological diagnosis to have spinal chondrosarcoma. The tumor locations were distributed as follows: 17 cases in the cervical spine, seven in the cervicothoracic spine, 23 in the thoracic spine, one in the thoracolumbar spine, and eight in the lumbar spine. Regarding surgical approaches, two patients underwent anterior-only resection, 27 underwent posterior-only resection, 22 underwent one-stage combined anterior-posterior approach surgery, and five underwent staged combined anterior-posterior approach surgery. The median total operative time was 357.5 minutes (range 107\u0026ndash;1,154 minutes), the median intraoperative blood loss was 1,000 mL (range 70\u0026ndash;5250 mL), and the median intraoperative blood transfusion volume was 1,100 mL (range 0\u0026ndash;6900 mL). In terms of comprehensive postoperative treatments, among patients whose resected margins transgressed the tumor (intralesional resection), 24 received postoperative radiotherapy and nine received postoperative chemotherapy. Among patients whose margins did not transgress the tumor (non-intralesional resection), six received postoperative radiotherapy and one received postoperative chemotherapy.\u003c/p\u003e\n\u003cp\u003eEn bloc resection of chondrosarcoma requires a large surgical field and extended operation time, resulting in significant damage to surrounding organs and tissues. Whether the resection transgresses the tumor significantly impacts perioperative management. To elucidate differences between en bloc resections with different surgical margins, we compared tumor characteristics, preoperative preparation, surgical approaches, intraoperative conditions, and postoperative radiotherapy and chemotherapy in patients undergoing intralesional versus non-intralesional surgeries (Table 2).\u003c/p\u003e\n\u003cp\u003eComparative analysis of the two groups revealed significant differences between intralesional and non-intralesional surgeries in terms of preoperative tumor arterial embolization, total operative time, and postoperative radiotherapy. No statistically significant differences were observed between the groups regarding tumor segment distribution, number of vertebral bodies resected, or surgical approach, indicating a balanced distribution between the groups. Additionally, no significant differences were found in total intraoperative blood loss, total intraoperative blood transfusion volume, or postoperative chemotherapy rate between the two groups.\u003c/p\u003e\n\u003cp\u003eSeven patients (12.5%) experienced dural tears during surgery, resulting in cerebrospinal fluid (CSF) leakage. Larger tears were repaired intraoperatively, and all healed after conservative postoperative treatment. In cases of large chondrosarcomas, especially those involving the thoracic spine, adhesion of the tumor mass to the parietal pleura or penetration of the visceral pleura led to tears or damage to the parietal or full-thickness pleura in 11 patients (19.6%) during surgery. Among these, one patient had lung tissue damage. All injuries were promptly repaired by the surgeon or thoracic surgery team.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerioperative complications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the study period, a total of 83 perioperative complications were recorded among 56 patients with spinal chondrosarcoma (Table 3), averaging 1.48 complications per patient. Forty-two patients (75.0%) experienced at least one perioperative complication. Specifically, 17 patients (30.4%) had one complication, 16 patients (28.6%) had two complications, and nine patients (16.1%) had three or more complications. These complications included 57 major and 26 minor events. Thirty-four patients (60.7%) had major complications, and no perioperative deaths were reported.\u003c/p\u003e\n\u003cp\u003eIntraoperative vascular injuries occurred in 16 cases (28.6%), involving the vertebral artery, epidural venous plexus, bone tissue, and intraspinal venous plexus. All cases received immediate vascular suturing. In these patients, the median operative time for non-intralesional surgery was 463 minutes, significantly longer than the 308 minutes for intralesional surgery (p = 0.007). Although no significant difference was observed in intraoperative bleeding and blood loss between the two surgical methods, hemostasis and vascular repair still required substantial time. Dural tears with CSF leakage occurred in seven cases (12.5%), and pleural injuries occurred in 11 cases (19.6%). The incidence of pleural injury was significantly higher in non-intralesional resection than in intralesional resection (p = 0.031). All dural and pleural injuries were immediately repaired during surgery.\u003c/p\u003e\n\u003cp\u003eRegarding early postoperative complications, neurological function deterioration occurred in 12 patients (18.7%). Postoperative manifestations included paralysis, unexpected decreases in limb muscle strength or hypoesthesia, and band-like sensations. The most severe cases exhibited muscle strength of grade 0\u0026ndash;1 in both lower limbs, which had not fully recovered by discharge. In two cases, planned intraoperative ligation of lumbar nerves led to decreased muscle strength in the lower limbs. In one case, stimulation of the recurrent laryngeal nerve during surgery resulted in postoperative hoarseness.\u003c/p\u003e\n\u003cp\u003eFourteen patients (25.0%) developed pleural effusion, requiring thoracentesis, closed thoracic drainage, or long-term thoracic drainage (\u0026gt; 7 days). All patients showed improvement after puncture or drainage. Postoperative pneumonia occurred in four cases (7.1%), which resolved after anti-infection treatment and oxygen therapy. Five patients (8.9%) experienced postoperative anemia and received blood transfusion therapy.\u003c/p\u003e\n\u003cp\u003eFour patients (7.1%) required debridement due to poor wound healing. Among them, one patient had a recurrent cervical chondrosarcoma after surgery at another hospital and underwent intralesional resection at our hospital in 2000. Postoperative wound healing was poor, and the patient still requires intermittent wound dressing changes during follow-up. In one case, intraoperative pleural damage was initially treated conservatively; after tumor resection, plastic surgeons repaired a large muscle defect. On the first postoperative day, wound dehiscence occurred and was managed by the plastic surgery team with debridement and suturing. Two patients (3.6%) developed deep vein thrombosis of the lower limbs, which improved after anticoagulant therapy without other complications such as embolism.\u003c/p\u003e\n\u003cp\u003ePostoperative imaging revealed that in one patient (1.8%), X-ray and CT scans showed slight rightward deviation of the 3D-printed artificial vertebral body, necessitating surgical adjustment. On the eighth postoperative day, the patient underwent wound exploration via a posterior lumbar approach, nerve root exploration, and adjustment of the artificial vertebral body. Postoperative internal fixation was satisfactory. Additionally, two patients (3.6%) developed postoperative chylothorax, and symptoms gradually disappeared after thoracic drainage, dietary control, and parenteral nutritional support.\u003c/p\u003e\n\u003cp\u003eWe compared the perioperative complications between intralesional and non-intralesional en bloc tumor resection surgeries (Tables 4\u0026ndash;5). In the intralesional surgery group, 25 patients experienced a total of 42 complications, while in the non-intralesional surgery group, 17 patients experienced a total of 41 complications. Statistical analysis revealed that the incidence of major complications was significantly higher in the non-intralesional surgery group compared to the intralesional surgery group (p = 0.028), indicating a statistically significant difference. Although no significant difference was found in the overall complication rate, the number of complications in the non-intralesional surgery group was significantly higher than that in the intralesional surgery group (p = 0.011). These findings suggest that non-intralesional en bloc resection of spinal chondrosarcoma, which requires complete and thorough removal of the tumor and surrounding tissues, entails higher surgical difficulty and is associated with more numerous, complex, and severe perioperative complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFollow-up and late complications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 56 patients, 7 died of tumor recurrence within 1 year postoperatively. The remaining patients were followed for at least 1 year, with an average follow-up duration of 48.1 months.\u003c/p\u003e\n\u003cp\u003eOne patient experienced internal fixation failure 38 months after surgery due to fracture of the titanium alloy fixation rod, necessitating revision surgery. This patient was followed-up for a total of 132 months after the first surgery, with no local tumor recurrence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLocal tumor control\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn analysis was conducted on the 56 patients with available follow-up data. Of these, 30 patients experienced tumor recurrence, yielding a recurrence rate of 53.6% (30/56). The mean time to recurrence was 24.8 months (SD = 29.6), and the median time to recurrence was 13.0 months (IQR = 29.0 months). Among the 36 patients who underwent intralesional resection, 25 experienced recurrence, and 24 of these had died by the time of follow-up. In contrast, among the 20 patients who underwent non-intralesional resection, 4 experienced recurrence, and 2 of these had died by the time of follow-up.\u003c/p\u003e\n\u003cp\u003eComparing postoperative local recurrence rates and mortality rates between the intralesional and non-intralesional en bloc resection groups, the non-intralesional group exhibited a significantly lower postoperative local recurrence rate (20.0% vs. 69.4%) and a markedly lower mortality rate at the final postoperative follow-up (15.0% vs. 52.8%). The RFS was further extended in the non-intralesional group, with a median RFS of 27 months and a median OS of 33.5 months. In comparison, the intralesional resection group had a median RFS of 18.5 months and a median OS of 41 months.\u003c/p\u003e\n\u003cp\u003eMultivariate Cox proportional hazards regression analysis was performed to assess postoperative recurrence and mortality risks, incorporating variables such as surgical margin status (whether the resection transgressed the tumor), tumor histological type, preoperative arterial embolization, total operative time, total intraoperative blood loss, perioperative complications, spinal segments with tumor involvement, involvement of vertebral bodies and accessory structures, and whether the pedicle was involved.\u003c/p\u003e\n\u003cp\u003eRegarding postoperative recurrence, two factors were associated with an increased risk (p \u0026lt; 0.1): surgical resection margins transgressing the tumor, special histological subtype of the tumor, and involvement of the sacral vertebrae. In terms of postoperative mortality, these factors were also linked to an increased long-term risk of death (p \u0026lt; 0.1): surgical resection margins transgressing the tumor, and special histological subtype of the tumor.\u003c/p\u003e\n\u003cp\u003eUnivariate log-rank survival analyses were performed on the above factors, and survival curves were plotted using the Kaplan-Meier method. It was further determined that non-intralesional en bloc resection (p = 0.012) and conventional-type chondrosarcoma (p = 0.022) were predictive factors for reduced long-term postoperative recurrence risk (Fig. 5). Similarly, non-intralesional en bloc resection (p = 0.028) and conventional-type chondrosarcoma (p = 0.027) were also predictive factors for reduced long-term postoperative mortality risk (Fig. 6).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eSpinal chondrosarcoma is a malignant tumor originating from cartilaginous matrix, accounting for approximately 20\u0026ndash;27% of all malignant bone tumors [9, 10]. The annual incidence of spinal chondrosarcoma is approximately one per million population. Primary spinal chondrosarcoma is relatively rare, representing approximately 2\u0026ndash;12% of all chondrosarcomas [1-3], and predominantly occurs in adults aged 40 to 60 years; it is uncommon in children and adolescents. Most spinal chondrosarcomas are not sensitive to radiotherapy and chemotherapy, although some agents (such as bisphosphonates and denosumab) have been used in treatment; therefore, surgical resection remains the preferred treatment option [7, 22-25].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEn bloc resection surgery has evolved through different surgical techniques. Both non-intralesional and intralesional en bloc resection can be achieved through the WBB resection and total en bloc spondylectomy. Schwab et al. reported on a team that treated 24 patients with primary spinal chondrosarcoma who underwent surgery [26]. Among these patients, 17 achieved negative surgical margins (wide resection). Of these 17 patients, three (18%) died by the last follow-up. In contrast, among seven patients with positive surgical margins (marginal and intralesional resection), three (43%) died by the last follow-up.\u003c/p\u003e\n\u003cp\u003eIn a 2000 study by Boriani and colleagues comparing piecemeal and en bloc resection of spinal chondrosarcoma [8], the authors suggested that en bloc resection can effectively prolong postoperative survival time and reduce the risk of local recurrence. Between 2011 and 2016, Wei Xu et al. described 15 cases of non-intralesional en bloc resection of paraspinal chondrosarcoma [27]. Five cases exhibited local recurrence, with an average postoperative recurrence time of 22 months. Yue Zhang et al. reviewed 49 cases of refractory recurrent spinal chondrosarcoma between 2001 and 2017, comparing prognoses between intralesional and non-intralesional resections [12],showing that patients who underwent non-intralesional surgery had significantly higher RFS and OS compared to those who underwent intralesional surgery. However, in 2018, Nisson et al. conducted a systematic review comparing the recurrence and prognosis of 11 non-intralesional surgery patients and 22 intralesional ones for primary spinal chondrosarcoma [28]. No statistically significant differences were observed in recurrence rates and mortality between the two groups.\u003c/p\u003e\n\u003cp\u003eAs a result, the relationship among resection methods, treatment efficacy, postoperative outcomes, and complications has not been clearly established through large-scale studies: whether achieving a non-intralesional margin should be the goal remains inconclusive.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerioperative complications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn our study, 75% of patients experienced perioperative complications, which is comparable to results reported in previous research, with Demura et al. [15] and Bandiera et al. [18] reporting postoperative complication rates of 67% and 50%, respectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding the incidence and number of major perioperative complications, the intralesional resection group had significantly lower rates than the non-intralesional resection cohort, indicating that the surgical safety of intralesional resection is relatively higher than that of non-intralesional resection.\u003c/p\u003e\n\u003cp\u003eMajor vascular injury is the most common intraoperative complication in en bloc resection of spinal chondrosarcoma, involving the vertebral artery, azygos vein, and paravertebral venous plexus. However, the incidence of such injuries after intralesional and non-intralesional resections (25% and 35%, respectively) showed no significant difference. We believe the main reasons are as follows: First, due to the rich distribution of venous plexuses anterior to the vertebral body, the extensive resection scope during en bloc tumor removal and the difficulty of separating anterior vertebral tissues via the posterior approach, there is a similar risk of major vascular injury regardless of whether the resection margins transgress the tumor. Second, up to 70% of non-intralesional surgeries involved preoperative embolization of the tumor\u0026rsquo;s feeding arteries\u0026mdash;a proportion significantly higher than that in intralesional surgeries, indirectly reducing the risk of major vascular injury caused by surgical manipulation. All patients achieved adequate hemostasis intraoperatively through vascular repair, packing, or electrocoagulation, and no cases of postoperative bleeding occurred.\u003c/p\u003e\n\u003cp\u003ePostoperatively, 12 patients (21.4%) experienced neurological function deterioration, including 6 patients in the intralesional group and 6 in the non-intralesional group. Six patients had unilateral or bilateral nerve roots of the corresponding segments severed and ligated during surgery, causing decreased muscle strength or paralysis of the lower limbs. Tumors resected via both intralesional and non-intralesional surgeries may involve nerve roots; therefore, the incidence of postoperative neurological dysfunction was similar between the two groups, with relatively favorable prognoses. In three patients, postoperative neurological function did not improve, and they remained paraplegic after rehabilitation training, possibly due to delayed spinal cord ischemia. In other cases, muscle strength and sensory function improved or returned to normal at discharge.\u003c/p\u003e\n\u003cp\u003ePleural effusion is a common postoperative complication, especially after surgery for thoracic spinal chondrosarcoma. In our study, the incidence of pleural effusion was 16.7% in the intralesional group and 40.0% in the non-intralesional group. Indeed, pleural injuries were significantly more frequent in the non-intralesional group (p = 0.031). This higher incidence may be due to more thorough and complete tumor removal, which increases the likelihood of pleural damage during thoracic tumor resection and extended resection margins. The perioperative management of such cases is critical, and closed thoracic drainage is essential. All patients had ceased drainage by the time of discharge, and the effusion gradually resolved.\u003c/p\u003e\n\u003cp\u003eCSF leakage is more common in surgeries for intradural tumors or during revision surgeries for tumor recurrence. The risk of dural tearing is unavoidable when the tumor adheres to the dura mater, regardless of whether the surgery is intralesional or not. In this study, intraoperative dural tears with postoperative CSF leakage occurred in four cases (11.1%) in the intralesional group and three cases (15.0%) in the non-intralesional group. All cases were successfully repaired and healed after conservative treatments such as bed rest and fluid replacement.\u003c/p\u003e\n\u003cp\u003eIn summary, compared with intralesional surgery, non-intralesional resection surgery for spinal chondrosarcoma was associated with a higher number of major complications. This suggests that non-intralesional surgery, while achieving a wider resection margin, may cause more trauma to surrounding organs and tissues, leading to an increase in the total number of perioperative complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLocal control\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrevious studies have fully confirmed that en bloc resection can significantly reduce local recurrence of spinal chondrosarcoma. Fisher et al. [29] analyzing a cohort of 111 spinal chondrosarcoma cases from 1987 to 2011, concluded that Enneking appropriate surgery is associated with a reduced risk of local recurrence but not with OS. In 2023, Abunimer et al. [30] based on a cohort of 72 patients, indicated that total en bloc resection of spinal chondrosarcoma is associated with local recurrence-free outcomes and improved OS. Xing-hai Yang et al. [31] further refined these conclusions, revealing the positive impact of en bloc resection on the prognosis of cervical and cervicothoracic chondrosarcoma. Huabin Yin et al. [32] conducted a retrospective study of 98 cases of spinal chondrosarcoma, emphasizing that total spondylectomy significantly reduces the risk of recurrence and distant metastasis while improving OS.\u003c/p\u003e\n\u003cp\u003eOur study results indicated that non-intralesional en bloc resection of spinal chondrosarcoma can reduce local tumor recurrence, improve survival rates, and extend RFS periods for patients. Although the non-intralesional surgical approach carries higher risks and more complications, choosing a more thorough resection without transgressing the tumor is necessary and valuable for achieving better therapeutic effects and prognosis. On the other hand, since non-intralesional en bloc resection has been applied in recent years with new surgical techniques, the number of cases is smaller, and the follow-up period is obviously shorter compared to intralesional surgery. The currently reported median survival time is also shorter, which may not fully reflect the survival situation after non-intralesional en bloc resection. However, from short-term analyses, it can still be concluded that en bloc resection with tumor-free margins can reduce mortality caused by tumor recurrence and extend the OS of patients with spinal chondrosarcoma.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLIMITATIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was a single-center, retrospective analysis and had certain limitations. First, spinal chondrosarcoma is relatively rare, making it challenging to obtain a large sample size for the case cohort. Second, the surgical cases included in this study span a period of 24 years. With the accumulation of surgical techniques and experience, and the advancement of materials and medical technology over time, ensuring consistency in treatment is very difficult. Consequently, when comparing cases from different periods, it is also challenging to eliminate the impact of this factor.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eTo achieve complete resection of spinal chondrosarcoma and reduce local recurrence, en bloc tumor resection is the preferred treatment. Regarding resection margins, although non-intralesional resection is more difficult and carries higher risks, and is associated with a greater number of perioperative complications, it can reduce the risk of local tumor recurrence, prolong RFS and OS, and provide patients with better prognoses. Therefore, when the condition and general health of patients with spinal chondrosarcoma permit, we recommend non-intralesional en bloc tumor resection surgery.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003estandard deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIQR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInterQuartile Range.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Disclosure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no funding resources to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare\u0026nbsp;no\u0026nbsp;potential conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the institutional research ethics committee ((IRB00006761-M2023022), according to the principles of the Declaration of Helsinki. 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Eur Spine J Apr 27(4):882\u0026ndash;890. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00586-017-5259-4\u003c/span\u003e\u003cspan address=\"10.1007/s00586-017-5259-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 5 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"chondrosarcoma, mobile spine, en-bloc spondylectomy, surgical margin, complication, prognosis","lastPublishedDoi":"10.21203/rs.3.rs-5317617/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5317617/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eStudy Design:\u003c/strong\u003e Retrospective Cohort Study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003e Chondrosarcoma of mobile spine is a rare aggressive malignant tumor and postsurgical local recurrence rates remain high. En bloc resection is currently the preferred treatment. Resection that achieves non-intralesional removal of the tumor may enable more complete removal of tumor tissue but significantly increases the complexity and risk of surgery and results in more postoperative complications. We sought to compare surgical outcomes, complications, and prognoses between patients who underwent en bloc resection with and without intralesional removal of the tumor.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe reviewed 56 patients with spinal chondrosarcoma who underwent en bloc tumor resection and reconstructive surgery at our center between 2000 and 2024 with a minimum postoperative follow-up of 1 year. We collected and analyzed data regarding surgical procedures, complication characteristics, and local tumor control and recurrence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eWe included 56 patients. Of these, 36 patients underwent the first surgery, and 20 experienced recurrences. All patients underwent en bloc tumor resection; 36 and 20 underwent intralesional and non-intralesional resections, respectively. We recorded 83 complications; the incidence and the number of major complications were significantly higher in the non-intralesional surgery group. Thirty patients experienced tumor recurrence and 26 patients died. Non-intralesional en bloc resection and conventional-type chondrosarcoma were predictive factors for reduced long-term postoperative recurrence and mortality risk.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eNon-intralesional resection carries higher risks and is associated with a greater number of perioperative complications, but reduces the risk of local tumor recurrence and prolongs recurrence-free survival and overall survival, providing patients with better prognoses.\u003c/p\u003e","manuscriptTitle":"Comparation of non-intralesional or intralesional spondylectomy for chondrosarcoma in mobile spine: a retrospective study of surgery management, complications, and prognosis.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-20 07:35:54","doi":"10.21203/rs.3.rs-5317617/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"68ef6f5f-df4f-421c-8b8b-7c5584926529","owner":[],"postedDate":"November 20th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-17T13:40:59+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-20 07:35:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5317617","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5317617","identity":"rs-5317617","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}